Summary

The Billing and Credentialing Specialist is responsible for the overall accuracy of the delegated rosters, for Medicare Medicaid and commercial payers’ compliance roster attestations and serving as liaison between Healthcare for the Homeless-Houston, and our billing companies. Also responsible for the timely and accurate billing and collections of Medicare, Medicaid and commercial payers. Must possess critical thinking skills and understanding of third-party payer payment methods to prepare contractual adjustments correctly based on payer contracts or government regulations. Responsible to submit electronic and paper claims to private and government payers, follow-up on submitted claims in accordance with payer and facility policies, research rejections and denials, document account activity, post adjustments and demonstrate proficiency with billing system to ensure all functionality is utilized for the utmost efficient processing of claims. Responsible to report billing and collection trends, problems and issues that result in delayed claim processing. Responsible to maintain current status on all private and government payer billing regulations and policies.  This is a multitask position and requires the flexibility to pivot upon need of the department, provider, MSO &/or patient.

Job Duties

• Prepares and maintains credentialing files and reports for all individual providers including maintenance of credentialing software, provider rosters and spreadsheets to comply with group delegation requirements.
• Obtains and verifies credentialing documents required.
• Ensures compliance with the appropriate accrediting and regulatory agencies in relations to credentialing functions including application management and primary source verification. Conduct onboarding document request and primary verification source.
• Coordinates the management of the expirable process to ensure all contracted provider licenses and certificates remain current, ensuring appropriate notification prior to expiration. 
• Revises general aspects of credentialing process as necessary; makes recommendations for changes in policies and procedures; assist in developing new process improvement strategies; maintains data integrity protocols and procedures
• Prepares for and coordinates credentialing audits in compliance with the managed care delegated credentialing contracts.
• Conducts file reviews to ensure documents meet credentialing standards and ensure all records meet standards set by carriers as well as FQHC guidelines
• Maintains quarterly payor specific rosters in accordance with CMS standards; conducts all follow up steps until payor approval/completion is obtained
• Processes and files applications with third party payors according to each payor’s individual requirements and addresses/corrects discrepancies as requested by payors.
• Files provider practice change notifications and perform follow up duties until confirmed complete by payors.
• Enrolls provider in Medicare/Medicaid as prescribed by each program requirements; Enrolls facilities in Medicare/Medicaid programs; Address enrollment disconnects regarding facility and providers
• Completes requests for re-credentialing for both providers and facilities.
• Accepts and processes requests from payers for credentialing information/updates/new contracts and products
• Answers questions, process requests from staff/providers related to credentialing information.
• Participates in the Performance Improvement Program.
• Assesses accuracy of demographic and policy information within patient accounts and updates as needed
• Responds to correspondence and phone calls related to patient accounts and is available to answer billing and charge related inquires by patients, staff, managed care organizations, etc. in a timely manner
• Documents all communication and transactions in patient accounts accurately and completely
• Identifies billing or coding issues and request re-bills, secondary billing, or corrected bills as needed
• Prepares and submits clean claims to all insurance companies either electronically or by paper.
• Researches and resolves claim holds/rejections and denials. Verifies patient benefits, eligibility and coverage as needed.
• Accurately researches and initiates correction of pertinent information for outstanding accounts receivable such as patient demographic and insurance information, relevant UB04/1500 claim form information and modifiers, and provider information as needed.
• Works Independently.
• Maintains patient confidence and protects medical office operations by keeping patient information confidential.
• Contributes to team effort by accomplishing related results as needed.
• Communicates with Leads to identify and resolve all RCM issues. 

Minimum Qualifications

• High school diploma or GED.
• Four years of relevant experience.